Endovascular Therapies for Hemodialysis Access · CASE REPORT AND REVIEW ... hemodialysis access intervention, hemodialysis, ... Monitoring the progress of fistula maturation was

CASE REPORT AND REVIEW

Vascular Disease Management® July 2014 145

Endovascular Therapies for Hemodialysis Access: Case Presentations of Salvage, Surgical Maturation, and Maintenance

GUIDELINES FOR HEMODIALYSISAs life expectancy increases and the incidence of

diabetes and hypertension grows, a greater number of

patients are diagnosed with advanced chronic kidney

disease. Chronic kidney disease eventually evolves into

end-stage renal disease (ESRD) necessitating place-

ment of permanent hemodialysis access. Permanent

dialysis access of arteriovenous connection has been

introduced and implemented since the 1960s.1 Ac-

cording to the National Kidney Foundation-Kidney

Dialysis Outcomes Quality Initiative (NKF-KDOQI)

and Society of Vascular Surgery (SVS) guidelines, it is

recommended that patients be referred for permanent

vascular dialysis access when creatinine clearance is

less than 25 mL/min.2,3 Arteriovenous fistula (AVF)

access has been the dialysis modality of choice over

arteriovenous graft (AVG) placement when suitable

vascular anatomy permits.3

ACCESS FAILURE, MATURATION, MAINTENANCE, AND SALVAGE

The primary causes for dialysis access failure in-

clude poor inflow by arterial anastomotic failure, poor

outflow due to central venous stenosis, small artery

or vein preventing adequate volume of blood from

circulating through the fistula, and collateral veins

stealing blood from the primary vein. The minimal

diameter of arteries and veins for access creation is

2 mm and 2 mm to 3 mm, respectively.2 Historically,

many fistulas that have failed initial cannulation were

Yury Bak, DO; John H. Cooper, DO; Kane L. Chang, MD

From the Deborah Heart and Lung Center, Browns Mills, New Jersey.

ABSTRACT: Arteriovenous (AV) access is a field in vascular interventional surgery that has under-

gone much evolution. Today many AV access sites are carefully monitored and facilitated, main-

tained, and salvaged through endovascular techniques. This enables the physician and patient to get

significantly more use out of each access site created. This article presents the development of the

endovascular field of access surgery. We also present illustrative cases that demonstrate examples

of using such techniques in our practice.

VASCULAR DISEASE MANAGEMENT 2014;11(7):E145-E155

Key words: hemodialysis access intervention, hemodialysis, arteriovenous fistula

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either abandoned or surgically revised. This resulted

in numerous procedures throughout the lifetime of

the patient to maintain dialysis access.

As the field of access surgery has evolved to better

understand the causes for fistula and graft failures, the

methods of treating dialysis problems have become

less invasive, more aggressive, and increasingly so-

phisticated. Initiatives of access salvage, access main-

tenance, and fistula maturation have become more

common concepts in hemodialysis. Fistula salvage

refers to transforming nonmaturing or thrombosed

fistulae to functional fistulae. Surgical maturation re-

fers to decreasing the maturation time for fistulae to

become usable with endovascular therapies. Finally,

maintenance is described as prolonging patency rates

of dysfunctional but patent fistulae. Arteriovenous

fistula abandonment appears to be twice as costly as

salvage of thrombosis with potential expenses per

patient-month of $707 vs $375.4 One of the main

factors that contributes to late access failure is intimal

hyperplasia. This is caused by activation of macro-

phages and release of chemotactic agents, including

platelet-derived growth factor, transforming growth

factor beta, and angiotensin II, all of which promote

migration of smooth muscle cells.4

PERCUTANEOUS VASCULAR INTERVENTION OF FAILING ACCESS

The earliest attempts at vascular access site salvage

were described in 1984 study, where 8 of 10 balloon

angioplasties were described as outright failures and

the authors concluded that percutaneous transluminal

angioplasty had a very limited role as an access site

salvage procedure in AV grafts.5 Angioplasty was later

combined with thrombolytic infusion in completely

thrombosed AVFs and AVGs with 78% primary pa-

tency at 3 months and 36% primary patency at 9

months.6,7 In lesions that are stenosed, the median

recurrence rate is 11 months in fistulas and 5 months

in grafts, and they had a 72% patency at 6 months and

32% patency at 12 months.8 When no lesions within

the vein are visualized, then the cause of fistula failure

may be arterial stenosis. Angioplasty may be safely

performed on the brachial artery to a primary patency

rate of 83% at 1 year and 74% at 2 years. Forearm

arterial access angioplasty is to be avoided in lesions

in very distal extremities.9 Endovascular placement of

stents was implemented for lesions resistant to bal-

loon angioplasty with primary patency of 100% at

6.2 months as described by Hood et al.10 Patency of

failing AV grafts was followed for a longer timeframe

with the use of Viabahn stents by Davila Santini et

al, with 94.7% 6- and 12-month patency, and 82.1%

18-, 24- and 36-month patency.11 The combination

of performing AVF angioplasty with ligation of ac-

cessory venous side branches that can steal direct ve-

nous flow from arterialized veins can achieve access

salvage in 82.5% to 100% of fistulas that fail to develop

with 84% continued function at 3 months, 72% at 6

months, and 68% at 12 months.12,13 More recently,

salvage of cephalic vein outflow has been described,

including a totally percutaneous tunneled bypass us-

ing stent grafts in the basilic vein outflow with good

intermediate follow-up results.14

FISTULA SURVEILLANCE AND MATURATIONMonitoring the progress of fistula maturation was

traditionally clinically assessed with adequacy of thrill

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and bruit over an enlarged vein. The use of ultrasound

duplex measurement of blood flows >700-800 cc/min

may effectively predict successful AVF maturation.14,15

Another study found a significant reduction in place-

ment of central venous dialysis catheters with use of

a surveillance program based on clinical and duplex

ultrasound every 3 months, followed by fistulogram

for stenosis compared to clinical and hemodynamic

assessment in cases of dysfunction.16 Frequently access

must be serially maintained with follow-up fistulo-

grams and interventions in order to preserve patency.

Falk analyzed 154 fistulas and determined that 3.3

procedures per fistula and 1.75 procedures per year

must be performed in mature fistulas to maintain pa-

tency. These procedures included arterial and venous

angioplasty, ligation of venous side branches, throm-

bectomy, and/or banding. The primary patency rate

at 1 year was 64% while secondary patency was 68%.17

The concept of serial dilations, known as balloon

angioplasty maturation, may be used to increase the

size of AVFs. Miller et al performed thrombectomy

with angioplasty of 140 immature thrombosed fistulas.

Average maturation time, defined as from thrombec-

tomy to maturation for dialysis, was 46.4 days with an

average of 2.64 interventions per patient. Percutane-

ous salvage of fistulas costs $4,881 to $14,998 less than

the abandonment and new creation of AV access.18

De Marco Garcia et al also achieved excellent func-

tion of AVF <3 mm in ≤2 months’ duration in 96%

of patients.19 Some have advocated performing endo-

vascular interventional procedures in an office setting

under ultrasound guidance. Gorin et al describes a

93% 90-day patency rate in 55 interventions where a

fistula was failing or not maturing. The overall rate

of perifistular hematoma was 11%, with 3 cases of

thrombosis of AVF. No patient required hospitaliza-

tion or urgent surgical intervention.20

CASE PRESENTATIONSCase 1

A 62-year-old male with history of coronary artery

disease, diabetes mellitus, hypertension, peripheral ar-

tery disease, and chronic renal insufficiency predialysis

underwent left radiocephalic end-to-side arteriove-

nous fistula. Intraoperative ultrasound demonstrated

a radial artery with high take-off at the axilla. The

radial artery was densely calcified, measuring 3.5 mm

above the elbow, and was poorly visualized below the

elbow due to calcification. Exploration of the radial

artery at the wrist demonstrated a 2.0 mm calcified

artery that was deemed marginal but usable for ra-

diocephalic fistula creation. The cephalic vein, which

measured 3.0 mm on ultrasound, was dilated to 3.5

mm intraoperatively prior to AVF creation. Excellent

flow was established at the conclusion of the AVF

creation. Two months postoperatively, the proximal

fistula measured 4 mm to 5 mm by ultrasound. Good

bruit and thrill were present over proximal AVF, but

were weak in the distal AVF. A large 5 mm collateral

vein was noted at the posterior forearm that appeared

to be stealing flow from the true cephalic outflow,

which measured 3.5 mm.

Two months after initial AVF creation, surgical li-

gation of the large collateral branch was performed

to divert flow back to the primary cephalic vein. On

ultrasound, the distal cephalic vein measured 3.5 mm

to 4.0 mm. The patient was lost to follow-up thereafter

and presented 15 months later, having progressed to

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ESRD and receiving hemodialysis via a permcath. It

was determined that some form of endovascular AVF

intervention was performed at another institution.

On physical exam, AVF contained a weak bruit and

thrill. Ultrasound of the fistula measured the proximal

cephalic vein at 5 mm to 6 mm. The middle portion

of the vein was occluded with no flow or compress-

ibility, whereas his distal cephalic vein reconstituted

and measured <2 mm. The patient was then taken to

the interventional suite for a fistulogram.

A micropunture needle was used to cannulate the

proximal vein in an antegrade direction. A 6 Fr short

sheath was then placed. An initial fistulogram showed

the proximal AVF and anastomosis to be patent with-

out stenosis. The middle cephalic vein appeared com-

pletely occluded, whereas the distal cephalic vein

above antecubital fossa reconstituted but was 1 mm

to 2 mm in size (Figure 1). A combination of Glide-

wire (Terumo) and Berenstein catheters was used to

traverse the occluded segment. Five thousand units

of heparin were administered and activated clotting

time was maintained >200. Angiojet (Bayer Health-

Care) mechanical thrombectomy was performed with

4 passes across the occluded segment (Figure 2).

Figure 1. Initial fistulogram showed proximal arteriovenous fistula and anastomosis to be patent without stenosis.

Figure 2. Catheters were used to traverse the occluded segment. Five thousand units of heparin were administered and activated clotting time was maintained at >200. Mechanical thrombectomy was performed with 4 passes across the occluded segment.

Figure 3. Balloon angioplasty performed to 6 mm at the previously thrombosed stenotic vein segment.

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Balloon angioplasty was then performed to 6 mm at the

previously thrombosed stenotic vein segment (Figure 3).

In addition, the cephalic outflow above the antecubital

fossa was noted to still be occluded. Additional Angiojet

mechanical thrombectomy was performed, revealing a

diminutively sized 1 mm to 2 mm cephalic outflow above

the antecubital fossa (Figure 4). Additional angioplasty

was performed on the small outflow vein to a final size of

6 mm. The central venogram demonstrated no residual

stenosis (Figure 5).

Excellent thrill and bruit were demonstrated at comple-

tion of the procedure throughout the cephalic vein. At 1

week postoperative visit, physical exam revealed excellent

bruit and thrill throughout the AVF. The cephalic vein

measured 5.6 mm to 7.2 mm throughout the forearm

and upper arm on ultrasound. There was no evidence of

residual stenosis present in the fistula (Figure 6).

The patient was seen in the office 1 week later and

cleared for dialysis via the fistula. The fistula was can-

nulated 2 weeks after the date of fistulogram and the

Permcath (Covidien) was removed shortly thereafter.

Case 2

A 72-year-old male with chronic renal insufficiency

and stage 4 chronic kidney disease had previously un-

dergone a radiocephalic AVF. Two months prior to

presentation, he was noted to have a diminishing thrill

over his fistula on follow-up. An elective fistulogram

was scheduled for salvage of the access site. On the

date of the fistulogram, a bruit was no longer present

and the fistula was noted to be occluded. After access

of the cephalic vein was obtained, a fistulogram was

Figure 4. Cephalic outflow above the antecubital fossa was occluded. Additional Angiojet mechanical thrombectomy was performed, revealing 1 mm to 2 mm cephalic outflow above the antecubital fossa.

Figure 5. Additional angioplasty was performed on the small outflow vein to a final size of 6 mm. The central venogram demonstrated no residual stenosis.

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performed, followed by Angiojet mechanical throm-

bectomy of the occluded cephalic vein (Figure 7).

This was followed by angioplasty with a 6 mm com-

pliant balloon (Figure 8). Further angioplasty was

performed on a persistent stenotic segment using a 6

mm noncompliant balloon with resolution of stenosis

and complete restoration of flow (Figure 9).

Case 3

An 82-year-old female with a history of ESRD had

undergone a right brachiocephalic AVF. She had

multiple subsequent interventions for central out-

flow stenosis. The patient returned to the office with

worsening swelling of the arm. An initial fistulogram

demonstrated severe central venous stenosis. Angio-

plasty was performed with an 8 mm noncompliant

balloon (Figure 10). Post dilation imaging revealed

excellent results (Figure 11).

Case 4

A 73-year-old male with stage 4 chronic kidney dis-

ease had previously received a brachiobasilic AVF. On

follow-up, he was noted to have a persistent massively

Figure 6. Ultrasound showed the cephalic vein measured 5.6 mm to 7.2 mm throughout the forearm and upper arm with no evidence of residual stenosis present in the fistula.

Figure 7. Fistulogram and mechanical thrombectomy of the occluded cephalic vein.

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swollen left arm. An initial fistulogram demonstrated

central venous outflow stenosis (Figure 12). Angio-

plasty was performed on the lesion (Figure 13) and

a post dilation fistulogram demonstrated resolution in

the outlet obstruction stenosis (Figure 14).

Case 5

An 85-year-old male with ESRD had a brachiobasi-

lic straight AVG previously placed. Prior intervention

necessitated placement of a covered stent for outflow

stenosis. He presented to the office with occlusion of

his AVG access. Initial fistulogram confirmed occlu-

sion of the AVG (Figure 15). A Glidewire was used

to traverse the occluded graft and outflow vein after

access was gained via a direct brachial artery punc-

ture. Angiojet mechanical thrombectomy was then

performed to reestablish access patency. Angioplasty

Figure 8. Angioplasty performed with a 6 mm compliant balloon.

Figure 9. Angioplasty of a persistent stenotic segment resulted in resolution of stenosis and complete restoration of flow.

Figure 10. Fistulogram demonstrated severe central venous stenosis. Angioplasty was performed with an 8 mm noncompliant balloon.

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was performed on the graft and outflow brachial vein

(Figure 16). Imaging post procedure showed excel-

lent flow through the fistula (Figure 17).

PRACTICE PATTERNS AND CONCLUSIONSAfter successful endovascular salvage of the failing or

thrombosed AV fistula, our patients are returned to the

care of their nephrologists, who will routinely obtain

monthly maintenance flow rates on dialysis. If these

measurements are suggestive of a failing fistula, they

will be referred back for evaluation and reintervention.

Generally, values less than 400-500 mL/min necessitate

vascular surgical consultation and a fistulogram based

on the KDOQI guidelines.

However, patients who are deemed high risk for

Figure 11. Post dilation results.

Figure 12. A fistulogram demonstrated central venous outflow stenosis.

Figure 13. Angioplasty of the lesion.

Figure 14. Fistulogram post dilation.

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recurrence of fistula failure, as evidenced by multiple

repeat interventions in the past, will be followed much

more closely by our vascular surgery service. These

patients will return every 3 months for routine physical

examination, careful questioning regarding the recent

history of their access function, and a duplex ultra-

sound performed directly by the vascular surgeon. We

typically will look for evidence of recurrent stenosis

based on axial diameter measurements of the fistula

flow lumen. Based on these findings, the decision

will be made for reintervention if needed. In patients

with recalcitrant stenosis who have had multiple in-

terventions with angioplasty, we tend to use covered

self-expanding stents such as Fluency (Bard Peripheral

Vascular) for treatment.

Hemodialysis access is a growing and exciting field

that has seen many advances. Careful patient selection

Figure 15. Fistulogram showing occlusion of the arteriovenous graft. Angiojet mechanical thrombectomy was performed to reestablish access patency.

Figure 16. The arteriovenous graft and outflow brachial vein were treated with angioplasty.

Figure 17. Excellent flow through the fistula at the conclusion of procedure.

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is necessary for placement of permanent dialysis access

with preference of fistula over graft. After completion

of the procedure, is it essential to continue to regularly

monitor the maturation of the access site. Multiple

techniques may be used to accelerate maturation of

an AVF. After successful cannulation of the fistula or

graft, it is essential to be aware of potential stenosis

from intimal hyperplasia over time that may cause

dysfunctional flow. Multiple endovascular meth-

ods, including thrombectomy, angioplasty, and stent

placement, may be used to salvage a failing access. n

Editor’s Note: Disclosure: The authors have completed

and returned the ICMJE Form for Disclosure of Potential

Conflicts of Interest. The authors report no conflicts of interest

regarding the content herein.

Manuscript received March 4, 2014; provisional acceptance

given April 2, 2014; final version accepted April 28, 2014.

Address for correspondence: Yury Bak, DO, Deborah Heart

and Lung Center, 200 Trenton Rd., Browns Mills, NJ

08015, United States. Email: [email protected]

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lowed by transluminal angioplasty. J Ultrasound Med. 2009;28(9):1159-1165.

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Documents

Endovascular Therapies for Hemodialysis Access · CASE REPORT AND REVIEW ... hemodialysis access intervention, hemodialysis, ... Monitoring the progress of fistula maturation was